ROANOKE TIMES
Copyright (c) 1996, Roanoke Times
DATE: Wednesday, March 27, 1996 TAG: 9603270003
SECTION: EDITORIAL PAGE: A-9 EDITION: METRO
SOURCE: FRANK H. BOEHM, M.D.
FOR THE past 30 years physicians, hospitals, insurance companies, pharmaceutical and medical-technology companies have had a free hand in determining the cost and degree of medical care. That era, however, is now over.
Many in medicine knew that the incredible rise in the cost of medical care would someday end. Yet, no one in or out of the medical field seemed to be able to change how medicine was practiced in this country. Now America has found a solution to the spiraling cost of medicine - ``managed care.''
Managed care is a process whereby patients are carefully programmed into a cost-containing environment utilizing a variety of tools such as primary care, gate keeping, evidence-based medicine, early discharge from hospitals, reduced fee for service, and HMOs (health maintenance organizations) to name just a few.
One technique already being used to lower medical costs in this country is blatantly unethical and should be stopped before it becomes ingrained into managed-care life. That technique uses financial rewards and penalties to influence physician behavior. It often results in hospitals and HMOs hiring or firing doctors based on their economic credentials, rather than on the quality of care they dispense.
In the late 1980s, most health maintenance organizations paid physicians a straight salary. Today, more than half of the HMOs pay physicians bonuses or inflict penalties depending on the cost of care they administer. This change came about because straight salaries did not reduce cost or expand corporation profits sufficiently. Physicians whose incomes are linked to reducing care admit fewer patients to hospitals, and give them less outpatient treatment than those simply on salary.
Such incentives are unethical. A physician free of incentives should, with appropriate guidelines and clinical pathways, be able to keep hospitalization and clinic visits to a reasonable limit while maintaining quality of care and at the same time reducing cost.
In some cases, physicians' payments are reduced by 50 cents on every dollar a patient spends in an emergency-room visit recommended by that physician. For example: A patient complains of chest pain late at night, calls his physician who refers him to an emergency room for evaluation. That process costs $1,000 and finds only indigestion as a cause of that pain. As a result, the referring physician is docked $500 from his or her paycheck. How will that physician react the next time the patient calls in the middle of the night with chest pain?
Many managed-care plans are collecting data on doctors, not to determine their medical experience, training, knowledge, judgment and outcome, but rather on how much their care is costing the managed-care plan. A doctor who spends the least money for care of his or her patients will be positively credentialed and kept on staff, while the physician whose care is the most costly will be negatively credentialed and in jeopardy of losing his or her practice.
This process ultimately puts the control of what kind of medical care is rendered to patients into the hands of nonphysicians - and this is unethical!
Doctors, not managers, should be making these decisions. While administrators can and should have a say in some aspects of care, most medical decisions should rest with the physician. However, physicians must establish evidence-based medical practices with well-thought-out and agreed-upon pathways of care. Without leadership by physicians in this area, Americans can expect more medical management by nonphysicians.
Make no mistake about it, administrators of managed-care plans are in many instances robbing physicians to pay themselves and stockholders. Recently, The New England Journal of Medicine pointed out that U.S. Healthcare, a large HMO, spends only 74 percent of its revenue on medical care, while maintaining a $1.2 billion cash reserve. In addition, the chief executive officer was paid $20 million and had $534 million in company stocks.
Managed care can be, and I believe eventually will be, an effective way to not only reduce the cost of medical care but also maintain quality of that care.
But guidelines and laws will need to be adopted to put an end to such activities as physician economic credentialing. It is unethical to do otherwise.
Frank H. Boehm, M.D., is professor of obstetrics/gynecology and director of obstetrics at Vanderbilt University Medical School in Nashville, Tenn. He wrote this column for the Boca Raton News.
- Knight-Ridder/Tribune
LENGTH: Medium: 85 lines ILLUSTRATION: GRAPHIC: Bob Newman/Newsday.by CNB